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An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
The admission to the hospital involves the production of an admission note. The leaving of the hospital is officially termed discharge, and involves a corresponding discharge note, and sometimes an assessment process to consider ongoing needs.
Inpatient care is the care of patients whose condition requires admission to a hospital.Progress in modern medicine and the advent of comprehensive out-patient clinics ensure that patients are only admitted to a hospital when they are extremely ill or have severe physical trauma.
A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician).
A district hospital typically is the major health care facility in its region, with large numbers of beds for intensive care, critical care, and long-term care. In California, "district hospital" refers specifically to a class of healthcare facility created shortly after World War II to address a shortage of hospital beds in many local communities.
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